500 S Anaheim Hills Rd, Suite 140, Anaheim Hills, CA, 92807
(714) 974-2220
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Home
Meet The Team
About Us
Videos & Podcasts
What We Treat:
Pediatrics
When To Visit
Advice by Pediatric Conditions
Immunization Policy
/
Sports Medicine
Advice by Sport
Advice by Sports Medicine Topics
Concussion Info & Exercises
Asthma / Bronchospasm Plan
Location & Contact
FAQs
Patient Forms
Videos
Blog
NOW OFFERING TELEMEDICINE ON-LINE VISITS WITH ANYTIME PEDIATRICS • Click here to begin
Mother's Name
(Required)
First
Last
Child's Name
(Required)
First
Last
Email
(Required)
Date
(Required)
1. I have been able to laugh and see the funny side of things
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
2. I have looked forward with enjoyment to things
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
3. I have blamed myself unnecessarily when things went wrong
Yes, most of the time
Yes, some of the time
Not very often
No, never
4. I have been anxious or worried for no good reason
No, not at all
Hardly ever
Yes, sometimes
Yes, very often
5. I have felt scared or panicky for no very good reason
Yes, quite a lot
Yes, sometimes
No, not much
No, not at all
6. Things have been getting on top of me
Yes, most of the time I haven’t been able to cope at all
Yes, sometimes I haven’t been coping as well as usual
No, most of the time I have coped quite well
No, I have been coping as well as ever
7. I have been so unhappy that I have had difficulty sleeping
Yes, most of the time
Yes, sometimes
Not very often
No, not at all
8. I have felt sad or miserable
Yes, most of the time
Yes, quite often
Not very often
No, not at all
9. I have been so unhappy that I have been crying
Yes, most of the time
Yes, quite often
Only occasionally
No, never
10. The thought of harming myself has occurred to me
Yes, quite often
Sometimes
Hardly ever
Never